Synopsis At approximately 2054, while proceeding downbound under Bridge11 in the Welland Canal, at Allanburg, Ontario, the bulk carrier Windoc was struck by the bridge's vertical-lift span, which was lowered before the vessel had passed clear of the bridge structure. The vessel's wheelhouse and funnel were destroyed. The vessel drifted downstream, caught fire, and grounded approximately 800metres from the bridge. Although the vessel's cargo of wheat was not damaged, the vessel was declared a constructive total loss. The bridge sustained structural damage, and the Welland Canal was closed to vessel traffic for two days. There were no serious injuries or oil pollution. Ce rapport est galement disponible en franais. 1.0 Factual Information 1.1 Particulars of the Vessels 1.1.1 Description of the Vessel The Windoc was originally constructed in Hamburg, (West)Germany, in 1959 as an ocean-going bulk carrier. In 1977, the vessel was rebuilt in Canada. The aft section of the vessel, where the propelling machinery, steering gear, and crew accommodation were arranged, was retained. The hull forward of the engine room was replaced to permit the carriage of more dry cargo, and the wheelhouse was moved aft above the accommodation. The vessel had six cargo holds. 1.2 Particulars of the Bridge 1.2.1 Description of the Bridge Bridge 11 is one of three vertical-lift bridges used for vehicular traffic over the canal. Bridge 11 is located in Allanburg, Ontario, 11.4nautical miles (nm) upstream from the breakwater at Port Weller, Lake Ontario (latitude 4304'35N, longitude 7912'38W). The bridge had been in continuous operation from the time it was built in 1932. Towers on each side of the canal are used to guide and support the raising and lowering of the span. A fixed camera mounted on top of the bridge's east tower provides the St. Lawrence Seaway Management Corporation (SLSMC) Traffic Control Centre (TCC) controllers a limited view of vessels approaching the bridge from upstream (i.e. from the south). The span was constructed of steel, and the road surface was paved with asphalt. The distance between the support bearings of the two towers reduced the width of the canal to 60.9metres(m). The clearance height between the span, when it was in the fully raised position, and the water level of the canal was 36.5m. The centre line of the span coincides with the centre line of the canal between the support bearings. The bridge operator's control room was located among the trusses above the centre line of the span. The engines and generators required to power and operate the span were housed directly above the bridge operator's control room. Signal lights, mounted along the centre line on each side of the span, are used to indicate to approaching vessels whether the span is stationary, in motion, or in the fully raised position. 1.3 Navigation in the Welland Canal 1.3.1 Traffic Control Centre (TCC) Control and scheduling of vessel traffic in the canal are provided by TCC controllers, as well as coordination of communications with vessels and canal organizations. Controllers communicate directly with vessels transiting the canal by very high frequency (VHF) radio. Controllers communicate directly, by landline and mobile telephone, with SLSMC personnel operating the locks and bridges to ensure overall coordination of vessel traffic. They are able to monitor vessel traffic in real time through the use of remote-controlled and fixed cameras placed throughout the canal. Controllers are also responsible for operating, by remote control, the only automated bridge in the canal. With respect to Bridge 11, there were three means of communication available between the operator and the TCC controller; landline telephone, VHF radio base-station and a VHFportable radio. Routine reporting of vessel traffic information between the operator and the controller was by landline telephone. Radio and telephone conversations between controllers and vessels, and between controllers and bridge and lock personnel, are recorded automatically at the TCC. There is a capability for video recording images captured by SLSMC cameras but it must be activated manually. 1.3.2 Procedures for Vessels Approaching Bridges Procedures for vessels approaching a bridge in the canal are stipulated in The Seaway Handbook3, a copy of which was in the wheelhouse of the Windoc. As a vessel's stem arrives at the black and yellow checkerboard whistle sign, a bridge operator activates an amber light which begins to flash. This signal acknowledges that the bridge operator is aware of the presence of the vessel and will start raising the bridge. If the amber light is not flashing, the vessel is to make its presence known to the bridge operator via VHF radiotelephone on the designated channel. After being acknowledged by the bridge operator, the signal lights on the bridge span, which turn red when in the fully-lowered position, will flash red once the operator begins to raise the span. The vessel may continue towards the bridge but shall not pass the limit of approach sign until the bridge span is in the fully-raised position and the signal lights turn green. The limit of approach sign for Bridge11 was located 60m from the bridge. As the bridge span is lowered, the signal lights on the span will turn from green to solid red. The operator control room of Bridge11 had a radar as well as a microwave detector receiver. The microwave detector is located at PortRobinson, approximately 2.2nm upstream from Bridge11. These devices are used to alert the operator of an approaching vessel when visibility is reduced. Both devices were fitted with alarms. 1.4 History of the Voyage 1.4.1 Windoc On 08 August 2001, the Windoc departed ThunderBay with a cargo of wheat for Montral, Quebec. At 1748 eastern daylight time (EDT)4 on 11August 2001, the vessel arrived at the southern entrance to the canal. It then proceeded under vertical-lift Bridge21 and bascule Bridge19A and entered Lock8. At 1923, it departed the lock, passed under bascule Bridge19, and proceeded downbound in the canal. Eight of the 22crew members on board were permitted to disembark from the vessel before it proceeded downbound. At 2028, the master of the vessel informed the TCC controller on VHF radiotelephone channel14 that the vessel was off PortRobinson. Accompanying the master in the wheelhouse were the third officer and a wheelsman. The vessel's speed over the ground averaged approximately six knots from PortRobinson to Bridge11. The vessel proceeded downbound, and the wheelhouse team observed the flashing amber approach light, located 925m from the bridge on the west side of the canal, which indicated that the bridge operator was aware of the approaching vessel. The speed of the vessel was reported to be approximately five knots. As the vessel neared the bridge, the signal lights on the bridge were flashing red and the lift span was being raised. When the vessel was approximately 0.75 to 0.5nm from the bridge, the signal lights changed to solid green and the lift span was in the fully-raised position. With the centre line of the vessel lined up with the bridge signal lights, the vessel proceeded under the bridge. When the vessel was approximately halfway under the bridge, the third officer observed that the bridge signal lights were solid red and the lift span was descending. At 2053, the master sounded a few blasts on the ship's whistle. The master, without identifying himself or the bridge in question, called the TCC on VHF channel14 about the lowering of the bridge. The master quickly stopped the engines and ordered an evacuation of the wheelhouse. Photo 1. Bridge 11 striking vessel in way of wheelhouse front windows. Reproduced with permission. The master and third officer left the wheelhouse by the starboard navigation bridge wing. As they proceeded down the external bridge access ladder, the span of the bridge struck the vessel in way of the wheelhouse front windows, subsequently destroying the vessel's wheelhouse and funnel (see Photo 1). Photo 2. Aerial view looking north at the bridge and vessel after the striking. (Photograph by Harry Rosettani) The wheelsman remained at his station in the wheelhouse and lay down on the deck as the bridge span passed overhead. He freed himself from the debris and descended by the deckhouse stairwell before the third officer returned to the wheelhouse to look for him. When the TCC controller heard a call on VHF channel14 about a bridge being lowered, he recognized the voice and used a camera, located at Seaway mile14.6, west of PortRobinson, to look at Bridge11. The controller saw that the stern of the vessel had not yet cleared the bridge, and the fixed camera mounted on the east tower of Bridge11 showed that the picture on the monitor was shaking. Thus, the controller concluded that the bridge had been lowered onto the vessel. After the striking, the vessel's general alarm was sounded. The crew mustered on the main deck and everyone was accounted for. The vessel drifted downbound from Bridge11. A fire broke out in way of the main engine casing and spread to the accommodation structure. The starboard anchor was dropped. However, the vessel's starboard bow made contact with the east bank of the canal. The vessel then drifted to the west side of the canal and went aground approximately 800m from Bridge11 (see Photo 2). 1.4.2 Bridge Operator On 11 August 2001, the operator was on his scheduled day off and had completed two 12-hour day shifts during the previous two days. The operator took two Darvon-N tablets at approximately 0800 that morning to relieve back pain and had consumed between two and four glasses of wine around lunch time. Between 1300 and 1400, he received a telephone call from an SLSMC team leader, who asked if the operator would agree to work an overtime shift that evening on Bridge11. The bridge operator agreed. No information concerning his fitness for work was exchanged at the time of the request, nor was it common practice to do so. SLSMC's policy is that no employee shall report to duty with their ability impaired. After the telephone call, the operator relaxed, ate, and tried to get some sleep but did not sleep. Reportedly, he did not consume any additional alcohol or take any medication after accepting to work the overtime shift. At about 1745, the bridge operator left his home and drove his vehicle to Bridge11. At about 1820, the operator arrived at the bridge and made his way onto the lift span. He was met by the bridge operator of the previous shift, who reported he should expect a busy shift that night. No other information was exchanged during the shift change. The operator then climbed up the access ladder and entered the bridge operator's control room to begin his shift. By 1857, the bridge operator had raised the lift span for the first time during his shift and informed the TCC controller by telephone that the vessel Algocape was under Bridge11. At that time, the operator had a brief conversation with the controller, who informed him that the next vessels he would encounter would be the downbound JohnB.Aird and two upbound yachts. The operator then lowered the lift span to allow vehicle traffic use of the bridge and later raised the lift span for the three vessels. At 1941, during the last telephone conversation between these two parties, the operator informed the TCC controller that the two yachts and the John B. Aird were under Bridge11. At 2050, the bridge operator called TCC by telephone and reported, in an unintelligible manner, that the Windoc was coming under [Bridge]11. The controller, listening to the bridge operator on a speaker, did not understand what was said and asked the operator to repeat his message. Immediately after that telephone call, the bridge operator called the TCC again. When the controller answered this call, the bridge operator sounded confused because he asked if he was calling Lock7. The TCC controller told the bridge operator he would relay the operator's message to Lock7 as that station was having trouble with its telephones. After the 2050 telephone call, the bridge operator began lowering the lift span. The operator reportedly lowered the span after he saw the stern of the vessel clear the bridge. The operator did not immediately report the striking of the vessel to the TCC. At 2054, after hearing the radiotelephone call on VHF channel14 about the lowering of a bridge on a vessel and seeing the picture on the monitor from the fixed camera mounted on top of Bridge11 shaking, the TCC controller called the bridge operator by telephone. The controller asked the bridge operator if he had lowered the bridge onto the vessel. The bridge operator told the controller that the vessel had hit the bridge. The controller told the bridge operator to raise the bridge. At 2056, TCC controllers received calls about an accident and fire at Bridge11. The controllers called the bridge operator several times but there was no response. It was not until 2106, when the controller called and spoke with the bridge operator that the operator expressed surprise that emergency services were on the way, questioning why emergency services personnel had a need to see him. When specifically asked by the controller about the fire on board the vessel, the operator reported that there was a small fire. At 2106, a police officer arrived at Bridge11. The lift span of the bridge was in the lowered but not fully-seated position, and the officer proceeded to the bridge control room to meet with the bridge operator. At 2110, an SLSMC supervisor arrived at Bridge11 and went up to the bridge control room to meet with the bridge operator. Shortly afterwards, other SLSMC personnel and emergency services arrived on scene. The police officer and the SLSMC area coordinator indicated that they found the operator sitting in the dark and described his condition as shaken up or in shock. An examination of the bridge operator's vital signs was conducted by a paramedic. The operator was asked by the paramedic to go to the hospital for further examination, but the operator declined his request. At approximately 2230, the bridge operator, accompanied by another person, left the bridge to return home. Following the occurrence, the operator did not recall any event between the time the decision was taken to lower the bridge and the time SLSMC personnel arrived at the bridge following the occurrence, a period of about 25minutes. 1.4.3 Communications Between Bridge 11 and the TCC Tapes of communications between the bridge operator and TCC controllers just before the time of the striking revealed that the operator was having difficulty communicating during this period. When the operator called the TCC to report that the Windoc was under Bridge11, the controller had difficulty understanding him and asked him to repeat the message. A short time later, the bridge operator again contacted TCC while attempting to contact Lock7. The operator had difficulty understanding that he had contacted the wrong place, his speech was slurred, and he asked the controller to relay his message to Lock7 on his behalf, which the controller agreed to do. This exchange was conducted over a speaker phone, and before hanging up, the two controllers on duty made comments about the way the operator sounded. Less than two minutes later, the accident occurred. Following the striking, TCC controllers had another two conversations with the bridge operator. The content of these communications indicate that the bridge operator did not seem to appreciate what had happened. 1.5 Effects of Darvon-N Darvon-N is the trade name for the chemical propoxyphene napsylate, a narcotic analgesic which acts on the central nervous system. Darvon-N is prescribed for the relief of mild to moderate pain where less potent medications are either not effective or are contraindicated. Darvon-N is ingested orally after which it reaches a peak concentration in the plasma of the individual in 2to 2.5hours. The duration of action5 is three to four hours. Propoxyphene napsylate is metabolized in the liver to become the chemical norpoxyphene. The half life6 of propoxyphene is 6to 12hours and that of norpoxyphene is 30to 36hours. Norpoxyphene also acts on the central nervous system but is significantly less potent than propoxyphene. Propoxyphene will interact with alcohol to produce additive effects on the central nervous system. 1.6 Speech Examination The assistance of the United States National Transportation Safety Board (NTSB) was requested to examine the recordings of telephone conversations between the bridge operator and the TCC for indications of possible impairment on the part of the bridge operator at the time of the occurrence. Based upon previous experience analysing the effect of psychological factors on speech, the speech analysis group examined 62telephone conversations between the bridge operator and the TCC which took place between 18June 2001 and 11August 2001. Two types of analysis were conducted. The first consisted of a comparison of physical characteristics of the operator's speech on the night of the occurrence to a baseline sample of the operator's speech on previous shifts. Measures used for the purposes of this analysis included: fundamental frequency; latency (time to respond when telephoned or when the telephone is answered); speech errors; speaking rate and the pronunciation of specific sounds such as land s. The second type of analysis by the speech analysis group was more qualitative and examined the recordings for overall quality and content on the night of the occurrence (see section 2.2). 1.7 TCC Coordination of Response Activities At 2054, after observing the shaking image from the camera mounted on Bridge11 and speaking to the bridge operator, TCC controllers made several attempts to contact the area coordinator via mobile radio and the Windoc via VHF radio, but were unsuccessful. Meanwhile, the TCC controllers continued to manage the vessel traffic in the canal. At 2056 and 2057, the TCC controllers received telephone calls from a dispatcher with Niagara Regional Police Service, requesting information about an accident at Bridge11. The dispatcher informed the controller that police, ambulance, and fire department were services on their way to the scene of the accident. The controller who spoke to the dispatcher provided little of the information that was available about the accident, but he did report seeing smoke. The controllers could see smoke on their monitors, but could not see the vessel or the span of the bridge. At 2100, the controllers made contact with the area coordinator (who was on duty at the time as the marine coordinator) and informed him of the accident at Bridge11. The area coordinator then proceeded to Bridge11. At 2103, the master of the Windoc, using a portable VHF radio, called the TCC to inform the controller that the vessel was on fire. By 2105, the TCC controllers had informed senior management and an SLSMC ship inspector about the accident. At 2108, in response to its query, the fire department was informed by the controller that a cargo of wheat was on board the Windoc. At 2110, the SLSMC area coordinator reported his arrival at Bridge 11 to the TCC and went to the bridge control room to meet with the bridge operator. At 2112, one of the TCC controllers called an SLSMC employee at Lock8 and requested that he go to Bridge11 but did not know to which side of the canal he should go. Meanwhile, the fire department called the TCC controller and inquired about the status of the bridge. The controller replied that contact had been made with the bridge operator, and the bridge span was approximately 10feet in the air. At 2113, the SLSMC ship inspector called the TCC controller and asked to which side of the canal he should proceed. The controller who spoke to the inspector stated that he could not see the vessel but believed it was closer to the east side of the canal. At 2123, the master of the Windoc called the TCC to voice his concern about a possible explosion and informed them that he was going to pull back his fire parties from the stern of the vessel. The master also suggested that the fire department should be able to apply water onto the vessel's stern from the west side of the canal. At 2125, the TCC controller relayed the master's suggestion to the fire department but did not mention his concern of a possible explosion. The concern was relayed to the fire department when the controller called back six minutes later. At 2127, a ship inspector, who had now arrived on scene, called the TCC controllers so that arrangements could be made to get him a small boat to board the vessel. A controller called the Port Colborne pilot boat and requested that the vessel proceed to Bridge11 to provide assistance. However, the pilot boat estimated that they would be at the site at approximately 2300. Furthermore, the pilot boat, with an air draught of approximately 22feet, would not be able to pass under the bridge to proceed to the Windoc. SLSMC did not want to raise the vertical-lift span until a thorough inspection of the bridge and support structures could be undertaken. The controllers began calling other vessels in the area and SLSMC personnel to find a small boat. The controllers were informed that the St. Catharines fire department had small boats that were being deployed to provide assistance in combatting the fire. The controllers were also informed that SLSMC had a small boat en route. At 2232, the fire department, after having gained access to a suitable launching site, launched its small boats. At 2253, the Canadian Coast Guard (CCG) Marine Communication and Traffic Services (MCTS) in Sarnia, Ontario, called the TCC about a news media report they received from the Ontario Ministry of the Environment (MoE) Spill Action Centre (SAC) about an accident at Bridge11. The controller informed MCTS that SLSMC was responding to the accident. There were no injuries or pollution, and they had not issued an accident report. Earlier, one of the controllers called a local radio station and left a message about the closing of Bridge11 to vehicular traffic as a result of an accident. At 2300, the fire department called the TCC and asked whether SLSMC was going to take precautions against a possible fuel oil leak from the vessel and whether MoE had been informed of the accident. After one of the controllers conferred with the SLSMC ship inspector, it was decided that prudence would dictate that an oil containment boom be deployed as a precautionary measure. The controller called a local spill response provider but there was no answer. The spill response provider has an after-hours telephone monitoring service, but the controller had hung up before being connected to the monitoring service. At 2309, the pilot boat arrived at Bridge11. SLSMC engineers boarded it and inspected the underside of the span. At 2310, a controller first called the fire department, then MCTS and SAC, to acquire an oil containment boom, but to no avail. At 2316, an officer with the CCG Rescue, Safety and Environmental Response Branch called the TCC and provided the controller with an erroneous 1-800 telephone number for the local spill responder. The telephone number was actually for MCTS in Sarnia, which did not have the requested telephone number but did provide the telephone number for another spill response provider located near Hamilton, Ontario. At the time of the accident, there was no standing agreement in place between SLSMC and a spill response provider for response services. At 2329, the controller was informed by an SLSMC employee that the Corporation had a boom but it would be difficult to deploy; 300feet of containment boom was located at the south end of the canal, 100feet was located at the north end. At 2355, the controller spoke to a spill response provider located near Hamilton who was able to provide and deploy an oil containment boom in the canal. It was deployed across the canal and downstream of the Windoc at approximately 0440 the following morning, six hours after boom deployment was first suggested. 1.8 Firefighting Response The initial explosion and fire had been fuelled by an incinerator fuel oil header tank located in the stack area. After mustering forward of the accommodation, the crew deployed hoses and began fighting the fire using the vessel's emergency fire pump. The initial shipboard firefighting efforts were successful in reducing the fire but, fearing an explosion from the engine room fuel oil day tanks, the crew was pulled back from the fire, leaving the fire hoses lashed in place directing water at the fire. Once municipal fire crews arrived on the canal bank adjacent to the vessel, the master evacuated the crew using a forward liferaft at 2200. The master and chief engineer remained on board to direct shore-based fire crews. The first of several reports of the striking made by the general public to the Niagara Regional Police Service was at 2056; police, fire, and ambulance services were dispatched to the scene of the accident. The Thorold Fire Department responded with pumper trucks, which arrived on the east side of the canal at 2105. However, the Windoc began to drift across to the west side of the canal, forcing the responding fire units to detour, arriving at the Windoc's final position at 2120. Due to a lack of common radio frequencies, the fire department initiated communications with the vessel by shouting across to the master. Initial reports from witnesses had indicated that some crew members had abandoned ship into the water; however, the master of the. Windoc reassured emergency services on scene that all of his crew was safe and uninjured. When the crew was evacuated from the vessel, the master sent a handheld VHF radio ashore for use by the fire department. Photo 3. Aerial view of aft section of vessel with fire department vehicle on site. (Photograph by Harry Rosettani) Since the Windoc's stern was approximately 20 m away from the canal bank and there was only the vessel's liferaft available for boarding, the fire department would not board the vessel initially. They started fighting the fire using portable pumps and hoses from aerial trucks (see Photo 3). The Thorold Fire Department did not have suitable boats to access the vessel; however, rigid bottom inflatable boats were provided later in the evening by the St.Catharines Fire Department. Neither TCC nor local fire departments were aware of boat launch ramps convenient to the occurrence site, thus delaying the arrival of the boats while a suitable launch site was located. At 2230, an SLSMC ship inspector boarded the Windoc, using the vessel's liferaft, to assist the captain and chief engineer, who remained on board when the crew was evacuated. At 2330, the seaway inspector observed that the aft bulkhead of the accommodation was warm to the touch and that the forward bulkheads were cool, indicating that the fire was still restricted to the aft portion of the accommodation. At 0145, seven members of the Thorold Fire Department boarded the Windoc to assess the situation and coordinate firefighting activities with the captain and chief engineer. At the time of the occurrence, the ship's fire plan had been stored in the wheelhouse, which was destroyed when the bridge struck the vessel. No copy of the plan was available outside of the accommodation. Notwithstanding the absence of a fire plan, firefighters were briefed by the captain and chief engineer. Using hoses and water supplied by the ship's emergency fire pump, firefighters entered the accommodation to reconnoitre at 0220. Due to their unfamiliarity with the layout of the vessel and the thick smoke, they did not remain inside to fight the fire and exited to the main deck at 0230. Under instructions from the fire chief, firefighters opened forward watertight accommodation doors in order to clear the smoke from the space. Shortly thereafter, the fire spread to the forward area of the accommodation into the captain's and chief engineer's cabins. Fire crews then fought the fire, discharging hoses through broken portholes in the forward bulkhead. At 0700, firefighters re-entered the accommodation, discharged the vessel's fixed carbon dioxide extinguishing system into the open engine room, and opened valves to direct water into the vessel's fixed sprinkler system. However, the sprinkler system piping was found to be damaged from the striking and fire, and the system could not be effectively charged. Fire crews continued to fight the fire from outside the vessel's superstructure during 12August 2001 until the fire was declared out at 1630. 1.9 Injuries to Persons 1.10 Damage Photo 4. View of damaged superstructure and funnel. 1.10.1 Damage to the Vessel The wheelhouse, main mast, engine room vents, and funnel were destroyed by contact with the lift span of the bridge. The incinerator fuel oil tank, located in the funnel casing, was ruptured, spilling fuel into the engine room and onto the boat deck. Accommodation on the various decks was destroyed by fire, heat, and smoke. The engine room casing and main engine were damaged by fire, heat and water. The bilge shell plating in way of starboard ballast tankNo.1 was creased and fractured. The aft bulkhead and bilge floors were distorted and torn adrift. The vessel was declared a constructive total loss. No damage to the cargo was reported (see Photo 4). 1.10.2 Damage to the Bridge Photo 5. Damage to Bridge 11. (Photograph by Thorold Fire Department) The bridge sustained structural damage to the centre of the vertical-lift span (see Photo 5). There was also damage at the extremities of the span as a result of lateral movement caused by the striking. Other than minor adjustments on the wire ropes which operate the bridge, there was no damage, mechanical or electrical, to the bridge's systems. Repairs to the bridge were carried out while the vertical-lift span was in the fully-raised position to permit vessel traffic to transit the canal. Upon inspection by SLSMC engineers, the bridge reopened to vehicular traffic on 16November 2001. 1.10.3 Damage to the Environment There was no damage to the environment. 1.11 Certification 1.11.1 Vessel Certification The vessel was issued certificates appropriate for the vessel type and geographic area of operation. 1.11.2 Bridge Certification The inspection of the bridge was carried out by SLSMC engineers. There is no requirement for a certificate to be issued. 1.11.3 Personnel Certification Crew qualifications were valid and conformed with regulatory requirements. There is no regulatory requirement for the operator of a lift bridge to be certified. The operator had received on-the-job training on bridge operation. 1.12 Personnel History 1.12.1 Master The master's command experience began in 1981. He had worked for several shipping companies and joined N. M. Paterson Sons Ltd. in 1989. He sailed as master on board the Paterson for five years and was a relief master for the Windoc, where he was assigned as master in 2000. He rejoined the vessel in June 2001, where he had been up to the time of the occurrence. 1.12.2 Bridge Operator In 1979, the bridge operator began working for SLSMC as a labourer. In 1985, he sustained a back injury and was assigned to light work duty in 1987. By 1989, he had received two weeks' training on operating a bridge and worked as a bridge operator. From 1991 to 1995, he worked as a lock operator. In 1995, he was re-assigned as a bridge operator. He worked the last four years prior to the date of the occurrence as an operator for Bridge11. The operator experienced a number of recurrences of his back condition since the 1985 injury, leading to absences in 1988, 1990, 1993 and 1994. He received medication for his back condition which included Tylenol III, Darvon-N, and other narcotic analgesics. The operator had changed doctors in 1998 and had not received prescriptions for such medication since that time. The Darvon-N taken on the morning of the occurrence was from a prescription dating back to 1997. The operator indicated that until that morning, he had not used Darvon-N for a considerable period of time, although he was occasionally taking anti-stress (Ativan) and pain (mefenamic acid) medication prescribed for his spouse. Both medications were kept in his locker in the operator's control room on the bridge. 1.13 The St. Lawrence Seaway 1.13.1 St. Lawrence Seaway System The St. Lawrence Seaway opened to deep-draught navigation in 1959 and is one of the world's largest waterway transportation systems. The Seaway provides ocean-going vessels access to ports west of the PortofMontral and within the GreatLakes. Vessels up to 225.5m in length and a draught of 8.0m are permitted to transit the Seaway. On average, it takes approximately eight to nine days to sail from western LakeSuperior to the AtlanticOcean, approximately 3700km. The average operating season is from March to December. Access between Lake Ontario and LakeErie is provided via the WellandCanal which is orientated north-south and is 43.4km long. The navigable channel is 106.7m wide and 9.1m deep. There are eight locks, which provide a total lift of 99.5m, and 10bridgeseither vertical-lift or basculewhich cater to vehicular and rail traffic. The height restriction for transiting vessels is 35.5m. In 1999, 3626vessels transited the canal. 1.13.2 St. Lawrence Seaway Management Corporation The St. Lawrence Seaway Authority (SLSA), a Crown corporation, was responsible for Canadian operations of the Seaway. The Authority was established in 1954 by an Act of Parliament to acquire lands and bridges for and to construct, operate and maintain a deep draught waterway between the Port of Montral and LakeErie. On 01October 1998, following commercialization of the Seaway, responsibility for Canadian operations and Seaway structure maintenance was transferred from SLSA to SLSMC, a not-for-profit corporation of Seaway users and other interested parties. The transfer of responsibility was pursuant to the Canada Marine Act and a 20-year renewable agreement with the Government of Canada. Under the agreement, the Government of Canada retains ownership of non-movable assets and the SLMSC submits a five-year asset renewal plan. Full-time Seaway staff was reduced from 794 in 1998 to 619 at the end of the 2001navigation season. Transport Canada (TC) retains regulatory authority for the Seaway. 1.13.3 Niagara Region Management SLSMC, Niagara Region, is responsible for overall operations and maintenance of the canal which is divided into three geographic areas of operation: north, central and south. The occurrence took place in the south area. An operations management teamcomprised of area managers, a marine services manager, and marine and area coordinatorsis responsible for supporting operations and vessel traffic management in the canal. (In the southern area of operation, the area manager was also the marine services manager.) To manage field operations, each geographic area of operation has a marine coordinator and an area coordinator. The marine coordinator is responsible for vessel traffic operations and the traffic controllers; the area coordinator is responsible for general maintenance and bridge operators. Hours of work for the marine coordinator and the area coordinator are from 0700 to 1900 and from 0800 to 1600, respectively. Between 1900 and 0700, only one marine coordinator is on duty for all three geographic areas of operation. Employee schedules are organized into four shifts; each shift has a team leader who reports to the area coordinator and assign tasks to employees within their teams. The team leader in the south area is also responsible for asking employees to work overtime. 1.14 Weather and Current At the time of the occurrence, in quickly approaching twilight conditions, visibility was good; there was no precipitation and winds were light. The speed of the current under Bridge11 was less than one knot in a northerly direction. 1.15 Lowering of Bridge Vertical-Lift Span The vertical-lift span in the fully-raised position had a clearance height of 36.5m above water level. While the amount of time to lower the span from the fully-raised position to the fully-seated position, a distance of 32.9m, varies with operators, completing the operation generally takes 1.5 to 2minutes. The span was being lowered when it struck the vessel in way of the wheelhouse front windows, at a height of approximately 18.6m above water level. It took between 49 and 65seconds to lower the span 18m. With the vessel travelling at a speed of approximately five knots, its bow would have been under or just clear of the bridge when the bridge operator began to lower the span. The approaching vessel's aft superstructure would have been visible to the bridge operator (whether seated or standing) through the south-facing control room window (see Figures 1 and 2, Photos 6 and 7). Figure 1. Diagram of a bridge operator's field of view when the bow of the vessel is under the operator's control room. Bridge is in the fully-raised position. Figure 2. Diagram of a bridge operator's field of view when the vessel is amidships under the operator's control room. Bridge is in the fully raised position. The area within the straight lines (i.e. ) represents the lower limit when the operator is seated at the control panel. The area within the dotted lines (i.e. -----------) represents the lower limit when the operator is standing at the control panel. Photo 6. Looking north from inside bridge operator control room with bridge in fully raised position (using fish-eye camera lens). There was no indication of any mechanical condition that would have prevented normal operation of the bridge at the time of the occurrence. The operator who worked the previous shift reported no problems with the bridge. The operator at the time of the occurrence had raised and lowered the bridge on two occasions without incident since beginning his shift and raising the bridge for the Windoc. Photo 7. Looking south from inside bridge operator control room with bridge in fully raised position (using fish-eye camera lens). The SLSMC's operations manual for Bridge11 states that the bridge may be lowered when it is observed that the stern of the vessel is clear of the bridge7. The bridge operator described having seen the stern of the vessel through the north windows of the control room (i.e. looking downstream the canal) where the door is located. 1.16 Emergency Preparedness 1.16.1 Contingency Planning, Training, and Exercising Pursuant to the Emergency Preparedness Act, federal ministers have a statutory responsibility to identify civil emergency contingencies that are within or related to the minister's area of accountability and to develop a civil emergency plan8. The St. Lawrence Seaway, including the canal, falls under the purview of the Minister of Transport. At the time of the occurrence, there was no current, local-level contingency plan in place to respond to emergencies within the canal. There was a draft version of the St.Lawrence Seaway Authority Contingency Plan for Major Failures or Accidents, dated 21December 1992, and a SLSMC Regional Marine Contingency Plan, revised March 1999; however, both plans and their appendices were not up-to-date. The draft plan for Major Failures or Accidents included a scenario of a vertical-lift bridge struck by a vessel, but the details of the response addressed the damaged bridge only. It did not address other possible vessel-related consequences of accidents and incidents, such as shipboard fires, evacuation, and pollution. The purpose of the Regional Marine Contingency Plan was to respond to discharges of dangerous, toxic or other substances on land and in waters for which the Corporation had responsibility. This included discharges from vessels within the Welland Canal. Both plans identified a command structure for the overall response operation; however, the command structures and the predesignated individuals to assume response roles were based on the organizational structure in place at that time. Procedures for reporting shipboard fires and the assistance to be provided by lock and bridge personnel were contained in the SLSMC's Traffic Control Manual, Niagara Region, 2000, and the Lock Operations Manual. Firefighting is conducted by local fire departments. The types of assistance to be provided were essentially focussed on directing the local fire department and authorities to the scene and ensuring that the deck of a vessel inside a lock was raised or lowered to a height that would permit evacuation of the crew. Of those who had responded to the accident, no one from SLSMC had received extensive training on managing a response to an emergency. A few SLSMC employees received some emergency-related training but it was restricted to pollution response. In 1996, six Seaway employees participated in a half-day pollution exercise and training session at the canal with CCG. A boom deployment exercise was scheduled to be conducted at the canal in 2000 but was cancelled. Other boom deployment exercises were conducted in 1999, 2000 and 2001 in the Montreal-Lake Ontariosection of the Seaway. A small vessel safety seminar for SLSMC employees operating small boats was provided by CCG in 1998. There was no record of a major vessel-related emergency exercise conducted with other agencies at the canal from 1990 up to the date of the occurrence. 1.16.2 Communications and Coordination The TCC provides a centralized communications network for day-to-day operations. Two controllers are assigned to each 12-hour shift. During emergencies, TCC controllers provide communications for coordinating emergency response activities, in addition to regular traffic management duties. SLSMC's Traffic Control Manual, Niagara Region, 2000, included emergency-related information and procedures, such as actions to be taken when an accident is reported; reporting accidents; firefighting aboard vessels; vessel groundings and collisions; a standby list of SLSMC personnel available on call, and environmental pollution. During an emergency situation, controllers are responsible for providing an initial response when immediate actions are required (such as fire, police and ambulance), to obtain information relating to an emergency and to inform the appropriate coordinators. The SLSMC marine services coordinator is responsible for forwarding information to MCTS who, in turn, will notify other authorities. The marine services coordinator is normally responsible for preliminary investigation of accidents. 1.17 Possible Source of Ignition An amateur video of the occurrence obtained by the Transportation Safety Board of Canada (TSB) shows numerous electrical arcs caused by wires being severed as a result of the impact with Bridge 11. As the funnel was torn from the engine room casing, exhaust piping from the main engine and two generators was breached, resulting in unshielded hot pipework and the release of hot exhaust gases and incandescent carbon. The hot, yet undamaged, exhaust collector piping at the main engine cylinder head level was also exposed to fuel vapour from the ruptured incinerator fuel oil tank. 1.18 Firefighting Capabilities 1.18.1 Shipboard Firefighting Capabilities The vessel's firefighting equipment and its installation was in accordance with existing requirements. On-board equipment included the following: an electricity-driven main fire pump in the engine room; a diesel-driven emergency fire pump in the bow thruster compartment; an accommodation sprinkler system and dedicated sprinkler pump in the engine room; a fixed carbon dioxide flooding system for the engine room; and fire control plans located in the wheelhouse. The partitions in the vessel's accommodation were built primarily of wood products which did not meet modern standards of structural fire protection. As a result, an extensive sprinkler system and stairwell fire doors had been installed throughout the accommodation and approved as providing an equivalent level of safety by Transport Canada Marine Safety. The sprinkler system piping was secured to combustible internal structures. All officers and crews, including the relief crew, were trained in firefighting and marine emergency duties. However, at the time of the occurrence, eight crew members were ashore and not available for firefighting or emergency response duties. The duplicate sets of fire control plans on board the vessel were all located within the accommodation structure and, because of the fire, were unavailable to the firefighters. 1.18.2 Shore-Based Firefighting Capabilities Five municipal fire departments (from municipalities adjacent to PortColborne, Welland and St.Catharines), with varying degrees of knowledge, experience and training in marine firefighting, were available in the canal area. The Thorold Fire Department, which was first to respond at the scene, had little or no experience or training in shipboard firefighting and was not equipped with suitable boats for transporting firefighters to and from the shore and the Windoc. The St.Catharines Fire Department was equipped with boats, and at the request of the Thorold fire chief, provided their boats for use at the scene. Given the relatively remote location of the Windoc's final position, no municipal water supply was available to help fight the fire. Pumpertrucks were used to draw water from the canal for use in fighting the fire. Given the high suction head caused by the height of the canal bank, difficulties were experienced initially in establishing suction for the pump; a lesser amount of water and water pressure was available for firefighting. 1.19 Fire Safety in Canadian Ports, Harbours and Seaway Since 1989, at least nine9 major fires have occurred aboard vessels of various types and sizes across Canada, involving a response by municipal shore-based firefighters. Occurrences involving the following three vessels are of particular interest: H.M. Griffith, Ambassador, and Petrolab. On 27September 1989, while transiting the canal, the bulk carrier H.M. Griffith experienced a fire in the tunnel area under its No.3 cargo hold. Post-occurrence concerns were raised, in a SLSA internal report, about communications and coordination of firefighting efforts between the vessel's crew and the municipal fire department. The report recommended that the SLSA arrange a meeting with local fire chiefs to establish procedures and clarify roles between them and municipal fire departments. At the time of the Windoc occurrence, no such procedure or memorandum of understanding was in place between the SLSMC and local fire departments in the canal area. In a subsequent occurrence in December1994, during the unloading of a cargo of rock phosphate in the PortofBelledune, NewBrunswick, a fire broke out in the conveyor belt system of the bulk carrier Ambassadorv. The combined efforts of the ship's crew and several shore-based fire departments were required to bring the fire under control; it was fully extinguished some 28 hours later. In Canadian ports and harbours, responsibility for risk assessment and emergency plans generally rests with the local port official, while firefighting is provided by the local fire department. Concerned that many municipal fire departments may not have properly trained personnel to fight shipboard fires, the Board made these three recommendations: The Department of Transport [should], in collaboration with ports and harbour authorities, take measures to ensure that shore-based fire brigades expected to support on-board firefighting receive appropriate training. The Department of Transport [should] take appropriate measures to ensure that on-board firefighting capabilities of vessels in Canadian ports and harbours are functional and readily available during cold weather operations. In its response, TC indicated that the Canadian Association of Fire Chiefs (CAFC) is responsible for the standards and training of shore-based fire brigades. CAFC has no jurisdiction over non-member fire departments. The majority of public harbours have only a local volunteer force to fight small fires, and their training generally does not include entering and fighting fires in restricted places. TC also indicated that, at present, there are no legislated requirements for public harbours and ports to engage in firefighting activities aboard vessels. Since 2000, TC has undertaken initiatives to improve marine firefighting at ports and harbours (see Section 4.1.4 for details). In May 1997, CAFC forwarded a questionnaire to selected municipalities to determine their firefighting capabilities and the type and extent of assistance that could be called upon by operators of marine terminals in the event of a fire on board a vessel in port. Information provided to TSB indicated that fire departments in the canal area were not sent copies of this survey, and therefore did not have an opportunity to participate. SLSA was not notified of these initiatives in 1997. Overall, the survey did not receive wide enough distribution to provide useful information for evaluating the scope of marine firefighting experience among municipal fire departments. On the evening of 19 July 1997, an explosion and fire occurred on board the tanker Petrolab at St.Barbe, Newfoundland, while the crew was washing cargo oil tanks in preparation for loading cargo. The ship's owner was killed and three crew members were injured by the explosion; one later died in hospital.10 The ensuing fire on board subsequently spread to the government wharf. The combined efforts of two CCG vessels and several shore-based fire departments were required to bring the fire under control. Both the ship and the government wharf were destroyed before the fire was fully extinguished some 63hours later. The subsequent investigation revealed that the local fire department was not equipped with foam and had no training in fighting shipboardin particular, oil tankerfires. As a result, fire departments did not bring the shipboard fire under control in its early stages, and burning paint on the vessel's outer hull spread the fire to the creosote-impregnated piles of the government wharf. Subsequent occurrences, in particular cargo fires on board the Southgate in 1998, and the Vaasaborg in 2001, further highlighted inadequacies in the efficacy of shipboard firefighting by shore-based fire departments. 1.20 Other Safety Action Concerning Safety-sensitive Positions In the transportation industry, fitness for duty of individuals engaged in safety-sensitive positions is key to furthering safety. Canadian seafarers are required to have a medical examination at specified intervals to maintain the validity of their certificates for use at sea.11 The Medical Examination of Seafarers Physician's Guide (TP 11343) sets out the factors to be taken into account in conducting medical examinations, and the physical requirements and tests to be used to establish whether a seafarer meets the requirements. A urinalysis examination is to be undertaken periodically if clinically indicated; however, it is not to be used for drug testing. In March 1991, TSB investigated an occurrence involving a collision between an icebreaker and a fishing vessel.12 The Board found no link between the icebreaker master's medical condition, or his medication, and the accident. Nevertheless, the Board was concerned about the lack of a formal mechanism to identify and monitor persons who are not medically fit for duty and who occupy safety-sensitive positions. In view of the lack of formal operational monitoring of a ship's crew member in a safety-sensitive position, who was on a regimen of prescribed drugs, and the lack of formal operational medical review before re-employment of a person returning to safety-sensitive duties following stress-related medical leave, the Board recommended that: The Department of Transport, in cooperation with Health Canada and the Canadian Coast Guard, define policies and procedures to ensure that personnel returning to safety-sensitive duties following any medical treatment are fit for those duties. (M95-05, issued July 1995) In response to the recommendation, CCG requires its crew members to have a medical examination in advance of certain voyages and following absences for reason of illness or injury. Those who are unfit shall not be assigned to a sea-going position until they are reassessed by a physician and found to be fit. The Crewing Regulations, which do not apply to CCG, were amended to provide authority to the Minister of Transport to require a re-examination of a seafarer at the request of the seafarer or the seafarer's employer. Prior to issuing or re-validating a Canadian commercial aircraft pilot licence, the candidate must undergo an annual medical examination and be free from any effect or side effect of any prescribed or non-prescribed therapeutic medication taken.13 On 19 December 2001, TC announced the implementation of the Railway Medical Rules for Positions Critical to Safe Railway Operations.14 These Rules establish a new medical assessment process and define medical fitness requirements for employees in operations critical to safety. A handbook15 was developed to provide Canadian railway companies and medical service providers with the information necessary to implement the Rules. The Railway Rules Governing Safety Critical Positions were also developed and define safety critical position and the type of records to be kept by the employer in connection with employees qualified to serve in safety-sensitive positions. In the United States, NTSB investigated two similar accidents involving light rail vehicles in the same location just six months apart. The investigation revealed that both operators in the accidents had been on medical leave for extended periods shortly before their respective accidents. Both had been prescribed medications with possible side effects that included fatigue and drowsiness. Since the investigation revealed that the authority did not require that employees occupying safety-sensitive positions report their use of prescription and over-the-counter medication before operating equipment, NTSB concluded that the authority lacked information that could have had a bearing on the condition and performance of such employees. Consequently, on 23 January 2001, NTSB issued the following recommendation (R-01-25) to the (United States) Federal Transit Authority: Authorize and encourage rail transit systems to require their employees in safety-sensitive positions to inform the rail transit system about their use of prescription and over-the-counter medications so that the rail system can have qualified medical personnel determine the medication's potential effects on employee performance. The response by the Federal Transit Authority to the NTSB recommendation indicated that the Authority has taken several actions to address the recommendation, such as initiating an assistance program for the transit industry on the potential hazards of medications. Tool kits containing checklists, educational and drug contradiction reference material, were also being developed to educate transit managers, supervisors and employees. There was no requirement, within SLSMC, for ongoing medical assessment of employees in safety-sensitive positions, nor was there a requirement for individuals in these positions to self-disclose the use of prescription medication to the employer.